Provider Demographics
NPI:1528303914
Name:BAUTISTA, MARLO (RN)
Entity type:Individual
Prefix:MR
First Name:MARLO
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 BELMONT AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-5938
Mailing Address - Country:US
Mailing Address - Phone:562-472-4337
Mailing Address - Fax:
Practice Address - Street 1:3205 N LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1733
Practice Address - Country:US
Practice Address - Phone:562-570-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594890163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health